Have you noticed if any Coroners recommendations have been adopted to produce, in any practical, meaningful way improved safety outcomes ?.
Have you noticed - in real terms, if there has been a pro active approach to reduce the self evident risks or casual factors related to the provided recommendations ?.
In the above case maybe not, but the coroner's court is the most effective forum for exposing every aspect of such tragic events; and certainly has proven effective at changing safety culture and regulation in other industries.
I have no idea of the nature of Mr Hempel's injury, but the change in behavior and nature WRT risk-taking seems consistent with frontal lobe injury. This really sounds like something that CASA should have been all over; monitoring the company in the immediate aftermath of his licence revocation and taking necessary enforcement action. If his licence was revoked due medical reasons then it sounds to me like the doctors did exactly as they were supposed to.
That said, allowing a non-licensed pilot to take fare paying passengers on commercial flights (regardless of the pilot's standing in the company and experience) constitutes criminal negligence. I wouldn't be surprised if they face a civil suit when this is all over, regardless of whether or not they are prosecuted criminally. Anyone who exposes passengers, and themselves, to such risk must be completely bloody stupid. Even if you end up having to drive a truck for a living, it's much better than ending up in this situation.